featherstone copia

8/3/2019 featherstone copia

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AGE 6 THROUGH ADULT

AUTHORSJohn D.6 . Fea th ers t one ,MSC, PHD, i s i n te ri m d ea n,Un iv er s it y o f Ca l ifo rn i a,S an F ra nc is co , S ch oo l o fD e nt is tr y, a nd i s a p ro fe s-s or , D ep artm en t o f P re -v ent iv e an d Re st or at iv eD en ta l S cie nc es , a t U C SF .D o ug la s A . Y o u ng , DDS,MS, MBA, i s a n a s so c ia tep ro fe s so r, Dep ar tm ento f Den ta l P r ac ti ce ,U n iv er si ty o f t he P ac if ic ,Arthur A . Du go ni S ch oo l o fDentistry.Sophi e Domejean -Or l i-aguet, DDS, i s a n a ss is ta n tp ro fe ss or , D ep artm en t o fO p er at iv e D e nt is tr y a ndEndodon ti cs, Un iver s it ed : t luvergne, Clermont-Fer-r and, F rance .

CDA JOURNAL, VOL 35, NOlO

Caries R isk Assessmentin Practice for Age 6Through AdultJOHN D.B. FEATHERSTONE, MSC, PHD; SOPHIE DOMEJEAN-ORLIAGUET, DDS;LARRY JENSON, DDS, MA; MARK WOLFF, DDS, PHD; AND DOUGLAS A. YOUNG, DDS, MS, MBA

A B 5 TRAe T The aim of this article is to present a practical caries risk assessmentprocedure and form for patients who are age 6 through adult. The content of the formand the procedures have been validated by outcomes research after several years ofexperience using the factors and indicators that are included.

Lar ry Jen son , DDS, MA,is fo rm er ly a h ea lth s ci-e n ce s c li ni ca l p ro fe ss o r,D e pa rt me nt o f P re ve nt iv ea nd R e st or at iv e D e nt alS ci en ce s, U n iv er si ty o fCa l ifo rn i a, San F ranc i sco ,S cho ol o f Den ti st ry .Ma rk Wo lf f, DDS, PHD, is ap ro fe ss or a nd c ha ir, D e-p artm en t o f C ario lo gy a ndC om pre he ns iv e C are , N ewYo rk U n iv er si ty C o ll eg e o fD e nt is tr y, N ew Yo rk .

Caries risk assessment is thefirst step in caries manage-ment by risk assessment,CAMBRA. The level of riskshould be used to determine

the need for therapeutic intervention andis an integral part of treatment planning.The management of caries following riskassessment for 6-year-olds through adultis described in this issue in detail in thepaper by Jenson et al. A separate formand procedures for use for newbornsto s-year-olds is presented in the paperby Ramos-Gomez et al. in this issue.

A group of experts from across theUnited States convened at a consensusconference held in Sacramento, Calif., inApril 2002. This group produced a cariesrisk assessment form and proceduresbased upon literature available up to thattime. The results were published in 2003."The consensus statement and supportingreview articles are available on the net:www.cdafoundation.org/journal.Thisform, or some variation of it, has been inuse in dental schools and private practicesfor as long as four years. Recent out-

comes research based upon the use of theprocedures in a large cohort of patients atthe School of Dentistry at the Universityof California, San Francisco, was recentlypublished, validating the form and proce-dures." The results from this study are thebasis for the current revisions to the cariesrisk assessment form and procedures pre-sented here. The successful componentsof the previous version have been re-grouped according to the outcomes resultsand are presented in TABLE 1.The form canbe readily adapted for use in electronicrecord systems, as has been done at UCSF.

The background, rationale, and step-by-step procedures are described as follows.

BackgroundSuccessful and accurate caries risk

assessments have been a dream fordecades. Numerous research papershave been written on the topic, suchas the reviews by Anderson et al. andAnusavice.>' Several forms and pro-cedures have been suggested, someof which are summarized in a recentreview by Zero et aP Individual contrib-

OCTOBER 2007 703
http://www.cdafoundation.org/journal.Thishttp://www.cdafoundation.org/journal.This


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DISEASE INDICATORSWhite spotsRestorations


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AGE 6 THROUGH ADULT

The second phase of caries risk as-sessment is by no means a mathematicalformula; it is better characterized as ajudgment based on the likely balancebetween the indicators and factorsidentified in the risk assessment form(TABLE 1) and illustrated visually in FIGURE1. The risk assessment form (TABLE 1)is comprised of a hierarchy of diseaseindicators, risk factors, and protec-tive factors that are based on the bestscientific evidence we have at this time.As mentioned previously, the risk assess-ment procedures published in 2003 havebeen assessed over more than three yearsand the outcomes led to the elimina-tion of some items and to the validationof those included here, together withvalidation of the tool to assess cariesrisk.'-" The determination of high-riskstatus is fairly clear. The decision to placesomeone in the moderate-risk categoryis sometimes not clear and differentpractitioners may reasonably come to dif-ferent conclusions. It is better to err onthe conservative side and place a patientin the next higher category if there isdoubt. As we get more clinical data theaccuracy of these risk assessment formswill no doubt increase even further.

Rationale and Instructions for Age 6Through Adult Caries Risk AssessmentForm

The following section presents therationale and instructions for the use ofthe form presented in TABLE 1: "Caries RiskAssessment Form - Children Age 6 andOver! Adults."

Caries Disease IndicatorsCaries disease indicators are clinical

observations that tell about the past car-ies history and activity. They are indica-tors or clinical signs that there is diseasepresent or that there has been recent

706 OCTOBER 2007

disease. These indicators say nothingabout what caused the disease or how totreat it. They simply describe a clinicalobservation that indicates the presenceof disease. These are not pathologicalfactors nor are they causative in any way.They are simply physical observations(holes, white spots, radiolucencies). Theoutcomes assessment described previ-ously and prior literature, highlight

IT IS BETTERto err on the

conse rvativ e s id eand p lace a p atientin the next higher

category ifth ere is d ou bt.

that these disease indicators are strongindicators of the disease continuing un-less therapeutic intervention follows.

The four caries disease indictorsoutlined in TABLE 1 are: (1 ) frank cavita-tions or lesions that radiographicallyshow penetration into dentin; (2 ) ap-proximal radiographic lesions confinedto the enamel only; (3) visual white spotson smooth surfaces; and (4) any restora-tions placed in the last three years. Thesefour categories are strong indicators forfuture caries activity and unless thereis nonsurgical therapeutic interventionthe likelihood of future cavities or the pro-gression of existing lesions is very high.

A positive response to anyone ofthese four indicators automatically placesthe patient at high risk unless therapeu-tic intervention is already in place andprogress has been arrested. A patient


with frank cavities has high levels ofcariogenic bacteria, and placing restora-tions does not significantly lower theoverall bacterial challenge in the mouth."

Caries Risk FactorsCaries risk factors are biological fac-

tors that contribute to the level of risk forthe patient of having new carious lesionsin the future or having the existing lesionsprogress. The risk factors are the biologi-cal reasons or factors that have caused orcontributed to the disease, or will con-tribute to its future manifestation on thetooth. These we can do something about.

There are nine risk factors recentlyidentified in outcomes measures of car-ies risk assessment" listed in TABLE 1: 1)medium or high MS and LB counts; 2 )visible heavy plaque on teeth; 3) fre-quent (> three times daily) snackingbetween meals; 4) deep pits and fissures;5) recreational drug use; 6) inadequatesaliva flow by observation or measure-ment; 7) saliva reducing factors (medica-tions/radiation/systemic); 8) exposedroots; and 9) orthodontic appliances.If there are no positive caries diseaseindicators (see above), these nine fac-tors in sum become the determinantsof caries activity, unless they are offsetby the protective factors listed below.

Caries Protective FactorsThese are biological or therapeutic factorsor measures that can collectively offsetthe challenge presented by the previouslymentioned caries risk factors. The moresevere the risk factors, the higher must bethe protective factors to keep the patientin balance or to reverse the caries process.As industry responds to the need for moreand better products to treat dental caries,the current list in TABLE 1 is sure to expandin the future. Currently, the protectivefactors listed in FIGURE 1 are: 1) lives/work/


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school located in a fluoridated community;2) fluoride toothpaste at least once daily; 3)fluoride toothpaste at least two times daily;4) fluoride mouthrinse (0.05 percent NaF)daily; 5)5,000 ppm F fluoride toothpastedaily; 6) fluoride varnish in last six months;7) office fluoride topical in last six months;S) chlorhexidine prescribed/used daily forone week each oflast six months; 9) xylitolgumllozenges four times daily in the lastsix months; 10) calcium and phosphatesupplement paste during last six months;and 11) adequate saliva flow (> 1ml/minstimulated). Fluoride toothpaste frequencyis included since studies have shown thatbrushing twice daily or more is significant-ly more effective than once a day or less.?Any or all of these protective factors cancontribute to keep the patient "in balance"or even better to enhance remineralization,which is the natural repair process of theearly carious lesion.

What to Do1.Take the patient details, the patient

history (including medications) andconduct the clinical examination. Thenproceed with the caries risk assessment.

2. Circle or highlight each of the "YES"categories in the three columns on theform (TABLE t). One can make specialnotations such as the number of cariouslesions present, the severity or the lack oforal hygiene, the brand of fluorides used,the type of snacks eaten, or the names ofmedications/drugs causing dry mouth.

3. If the answer is "yes" to anyone ofthe four disease indicators in the firstpanel, then a bacterial culture shouldbe taken using the Caries Risk Test(CRT) marketed by Vivadent, (Amherst,N.Y.). (*-See below or equivalent test.)

4. Make an overall judgment as towhether the patient is at high-, moder-ate- or low-risk dependent on the bal-ance between the disease indicators/risk

factors and the protective factors usingthe caries balance concept (see bottomof T AB L E ' and FI G URE t). N O T E : Deter-mining the caries risk for an individualrequires evaluating the number andseverity of the disease indicators/riskfactors. An individual with caries lesionspresently or in the recent past is athigh risk for future caries by default. Apatient with low bacterial levels would

FLUORIDE TOOTHPASTEfre quency is includedsin ce stu dies h av e

shown th at b rush in gtw ice daily or more is

significantlymore effective thanonce a day or less.

need to have several other risk factorspresent to be considered at moderaterisk. Some clinical judgment is neededwhile also considering the protec-tive factors in determining the risk.

5. If a patient is high risk and hassevere salivary gland hypofunction orspecial needs, then they are at "extremerisk" and require very intensive therapy.

6. Complete the therapeutic recom-mendations section as described in thepaper by Jenson et al. this issue, basedon the assessed level of risk for futurecarious lesions and ongoing cariesactivity. Use the therapeutic recom-mendations as a starting point for thetreatment plan. The products that canbe used are described in detail in Jensonet al. and Spolsky et al. in this issue.

7. Provide the patient with thera-peutic and home care recornmenda-


tions in the form of a letter, basedon clinical observations and theCaries Risk Assessment result.

S. Give the patient the sheet thatexplains how caries happens (F I G URE 2 )and the letter with your recommenda-tions. Sample letters are given. Moredetails about these recommendations andprocedures are laid out in Jenson et al. inthis issue. Products that should be usedare described in detail in Spolsky et al.

9. Copy the recommendations and theletter for the patient chart (or if you haveelectronic records the various form lettersand recommendations can be generated tobe printed out custom for each patient).

10. Inform the patient of the resultsof any tests. e.g., showing the patientthe bacteria grown from their mouth(CRT test result*) can be a good motiva-tor so have the culture tube or digitalphotograph of the test slide handy atthe next visit (or schedule one for thispurpose - the culture keeps satisfacto-rily for some weeks), or give/send thema picture (digital camera and e-mail).

11.After the patient has been follow-ing your recommendations for three to sixmonths, have the patient back to reassesshow well they are doing. Ask them if theyare following your instructions, how often.If the bacterial levels were moderate orhigh initially, repeat the bacterial cultureto see if bacterial levels have been reduced.Some clinicians report improved patientmotivation when a second bacterial testis done initially immediately after thefirst month of antibacterial treatment.Documenting a "win in your column" earlyon is a valuable tool to encourage patients.Make changes in your recommendationsor reinforce protocol if results are not asgood as desired, or the patient is not com-pliant. Refer to Jenson et al. this issue formore detail on protocols and procedures.

CO N TIN UES O N 710

OCTOBER 2007 707


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AGE 6 THROUGH ADULT

AGE 6 THROUGH ADULT, CONTINUED FROM 707

H ow Tooth D ecay H ap pensT ooth decay is caused b y certain types of b acteria (m utans strep tococci

and lactob acilli) that live in your m outh. W hen they attach them selves tothe teeth and m ultiply in dental plaq ue, they can do dam age. T he b acteriafeed on w hat you eat, especially sugars ( includ ing fru it sugars) and cookedstarch (b read, potatoes, rice, pasta, etc.) . W ith in just a few m inutes afteryou eat, o r drink, the b acteria b egin producing acids as a b y-product of theirdigesting your food . T hose acids can penetrate into the hard sub stance ofthe too th and disso lve som e of the m inerals (calcium and phosphate) . If theacid attacks are infreq uent and of short duration , your saliva can help torepair the dam age b y neutraliz ing the acids and supply ing m inerals and fluo-ride that can replace those lost from the tooth. H ow ever, if: 1 ) your m outh isdry; 2) you have m any of these bacteria; o r 3 ) you snack frequently ; then thetoo th m ineral lost by attacks of acids is too great, and cannot b e repaired .T his is the start of too th decay and leads to cavities.

FIG U R E 2. H ow to oth d ec ay h ap pe ns ( to b e g iv en to e ac h p atie nt) .

*T est procedures - S aliva F low R atea nd C a rie s B a ct er ia T e st in g

*1. Saliva Flow Rate: Have the patientchew a paraffin pellet (included withthe CRT test - see below) for three tofive minutes (timed) and spit all salivagenerated into a measuring cup. At theend of the three to five minutes, mea-sure the amount of saliva (in milliliters= ml) and divide that amount by time todetermine the ml/minute of stimulatedsalivary flow. A flow rate of1ml/minand above is considered normal. A levelof 0.7 ml/min is low and anything at 0.5ml/min or less is dry, indicating severesalivary gland hypofunction. Investigationof the reason for the low flow rate is animportant step in the patient treatment.

*2. Bacterial testing: An example (othersare currently available) of a currently avail-able chairside test for cariogenic bacterialchallenge is the Caries Risk Test (CRT)marketed by Vivadent. It is sufficientlysensitive to provide a level oflow, medi-um, or high cariogenic bacterial challenge.

710 OCTOBER 2007

It can also be used as a motivational toolfor patient adherence with an antibacterialregimen. Other bacterial test kits will likelybe available in the near future. The follow-ing is the procedure for administering thecurrently available CRT test. Results areavailable after 72 hours (note: the manu-facturer's instruction states 48 hours, butmore reliable results are achieved if theincubation time is 72 hours). The kit comeswith a two-sided selective media stick thatassess mutans streptococci on the blueside and lactobacilli on the green side.

a) Remove the selective media stickfrom the culture tube. Peel off the plasticcover sheet from each side of the stick.

b) Pour (do not streak) the col-lected saliva over the media oneach side until it is entirely wet.

c) Place one of the sodium bicar-bonate tablets (included with thekit) in the bottom of the tube.

d) Replace the media stick in theculture tube, screw the lid on and labelthe tube with the patient's name, registra-


tion number, and date. Place the tube inthe incubator at 37-degrees Celsius for 72hours. Incubators suitable for a dentaloffice are also sold by the company.

e) Collect the tube after 72 hoursand compare the densities of bacte-rial colonies with the pictures providedin the kit indicating relative bacteriallevels. The dark blue agar is selective formutans streptococci and the light greenagar is selective for lactobacilli. Recordthe level of bacterial challenge in thepatient's chart, as low, medium or high.Some find it helpful for documentationto number the pictures 1hrough 4.

S a mp le P at ie nt L et te rs /R ec om m en da tio ns fo r C on tr ol o fD en ta l D ec ay (A ge 6 a nd O v er /A du lt)

One of the following letters (FIGURESa-s nncluding home care recommenda-tions should go to each patient depend-ing on the risk category and the overalltreatment plan (refer to Jenson et al.this issue for treatment plan details) .


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D ea r ( Pa tie nt X ) ,C on gratu latio ns, y ou h av e b een assessed at lo w risk fo r fu tu re d en tal d ecay . W e w an t to h elp y ou stay that w ay . Y ou w ill f in d th at yo u w ill b e ab leto m ain tain y ou r cu rren t lev el o f o ral h ealth if y ou d o th e fo llo win g: B ru sh tw ic e d aily w ith an o ve r-th e-c ou nte r flu orid e-c on ta in in g to oth pa ste. R ev iew w ith u s y ou r d ietary and o ral h yg ien e h ab its an d receiv e o ral h yg iene in stru ctio ns. If g oo d, co ntin ue w ith y ou r ex istin g d ietary and o ralh yg ien e h ab its u nless th ere is a ch an ge in statu s, su ch as n ew m ed icatio ns. G et a th oro ug h p ro fessio nal clean in g as n eed ed fo r yo ur p erio do ntal h ealth . W e w ill b e h ap py to p ro vid e th ese clean in gs fo r y ou . Return for a caries recall ex am (w hen req uested) in six to 1 2 m onths to re-evaluate your current caries risk. H ave new b itew ing radiographs (X -rays) taken ab out every 2 4 to 3 6 m onths to check for cavities. C on sid er u sin gx ylito l g um /cand ies an d o ver-th e-co un ter flu orid e rin se ( 0.0 5 p ercen t so diu m flu orid e) in stead o f reg ular g um /can dy o r m ou th -wash. G et fluoride varnish after teeth cleanings, b ase line b acterial test, sealants if y our dentist recom mends it. Y ou m ayor m ay not need this. Itd ep en ds o n y ou r o ra l c on diti on s. O th er r ec ommen da tio ns :

FI GUR E 3. Low caries risk.

D ea r ( Pa tie nt Y ),Y ou have b een assessed to b e at m oderate risk for new dental decay in the near future because you have (fill i n the b lank) . W e w ant you to m oveinto a safer situation to avoid new decay in the future. H ere are som e w ays to accom plish this goal: R ev iew y ou r d ietary an d o ral h yg ien e h ab its w ith us an d receiv e o ral h yg ien e in stru ctio ns. B ru sh tw ic e d aily w ith a n o ve r- th e- co un te r flu orid e-c on ta in in g to oth pa ste , fo llo win g th e o ra l h yg ie ne in stru ctio n p ro ce du re s y ou h av e b ee ngiven. P urch ase an o ver-th e-co un ter flu orid e rin se ( 0.0 5 p ercen t so diu m flu orid e, e.g . F lu orig ard o r A CT ) an d rin se w ith 1 0 m l ( on e cap fu ll) o nce o rtw ice d aily after y ou h av e u sed y ou r flu orid e to oth paste. C on tin ue d aily u ntil y ou r nex t d en tal ex am . G et a thorough professional cleaning from us as needed for your periodontal health. C hew o r su ck x ylito l-co ntain in g g um o r can dies fo ur tim es d aily . R eturn w hen req uested for a caries recall ex am in four to six m onths to re-evaluate your progress and current caries risk. G et n ew b itew in g rad io grap hs (X -ray s) ab ou t ev ery 1 8-2 4 m on ths to ch eck fo r cav ities. G et a fluoride varnish treatm ent every four to six m onths at your caries recall ex am s. Y ou m ay also n eed a b ase lin e b acterial test an d sealan ts (d ep en din g o n y ou r situ atio n an d co nd itio n). O th er r ec ommen da tio ns :

FIG URE 4. Moderate caries risk.

OCTOBER 2007 71 1


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AGE 6 THROUGH ADULTCDA JOURNAL, VOL 35, NOlO

D ea r ( Pa tie nt Z ),O ur assessm en t rev eals you are at a h igh risk of h avin g n ew den tal d ecay in t he near future b ecause yo u h ave ( fill i n th e b lank) . W e w ant to helpy ou to m ove to a safer situ atio n to avoid new d ecay if at all possib le. W e stro ngly recommend th e follow ing: C om plete a caries b acterial test w ith u s today (as a b ase lin e b efo re antib acterial therap y). W e w ill hav e the results of th is test in three days. C om plete a saliv a flow m easu rem ent to ch eck fo r d ry m outh . T his is a v ery sim ple test th at w e w ill d o tod ay as part of the b acterial assessm en t. R eview w ith us your d ietary an d oral hyg iene hab its and receive instructions on b oth. T he m ost im portant thing is to red uce the nu mb er ofb etw ee n-me al s we et s na ck s th at c on ta in c arb oh yd ra te s, e sp ec ia lly s ug ar. S ub stitu tio n b y s na ck s r ic h in p ro te in , s uc h a s c he ese , w ill a ls o h elpas w ell as the x ylitol gu m or candies describ ed b elow . B rush tw ice daily w ith a high flu oride tooth paste, either C on tro l R X o r P rev ident P lus tooth paste (5 ,0 00 parts per m illion fluo rid e). W e w illp ro vid e s om e fo r y ou to da y. T his is to b e u se d tw ic e d aily in p la ce o f y ou r re gu la r to oth pa ste . R inse for on e m inu te, once a day w ith a special an tib acterial m outh rin se w e w ill p rov ide for yo u today . I t is called Peridex or P eriogard an dh as a n a ctiv e in gr ed ie nt c alle d c hlo rh ex id in e g lu co na te a t 0.12 percen t. Y ou sh ould u se this o nce daily just b efore b ed at nig ht (10 m l f or o nem inu te) , b ut on ly for one w eek each m onth. Y ou m ust u se this at least o ne hour after b rushin g w ith th e 5 ,0 00 p pm fluorid e too thpaste. H a ve th e n ec ess ar y r esto ra tiv e w or k d on e, s uc h a s fillin gs o r c ro wn s, a s n ee de d, in a m in im ally in va siv e fa sh io n. Su ck o r chew x ylitol can dies or gu m fo ur tim es daily. Y o u c an ob tain supplies from us to day or w e can help you b uy these elsew here. G et sealants applied to all of the b iting surfaces of your b ack teeth to keep them from b eing reinfected w ith the b acteria that cause dentaldecay. W e w ill b e h appy to d o th is for yo u. R eturn w hen req uested for a caries recall ex am in t hree to four m onths to re-evaluate your progress and current caries risk . Particip ate in ano ther caries b acterial test at y our caries recall ex am or earlier to com pare results w ith y our first visit. T his w ill a llow us toche ck whet he r t he chl orhe x id in e i s wo rk in g s at is fa ct or il y. A llow us to rev iew you r use of chlo rhex idine and C ontrol R X /Previd ent an d oral hyg iene at that v isit. G et a thoroug h professio nal cleaning as need ed for yo ur periodo ntal h ealth. G et new b itew ing radiographs ( X-rays) ab out ev ery six to 1 8 m onth s to check for cavities. G et a fluo rid e varnish treatm en t for all o f your teeth every three to four m on ths at yo ur caries recall ex am s. O th er r ec ommen da ti on s:

FIGURE 5. High cari es r isk.

REFERENCES1.Featherstone JD,Ada ir SM, e t a l. Car ies management byr isk assessment: consensus statement , Apri l 2002. J Ca lDen tAssoc 31(3):257-69, March 2003.2. Domejean-Or liaguet 5, Gansky SA, Featherstone JD, Car iesr isk assessment inan educational environment .J Dent Educ70(12):1346-54,2006.3. Anderson MH, Bales DJ, Omnel l K-A, Modern managementof dental caries: the cutting edge is not the dental bur. J AmDe nt A s so c1 2 4: 3 7- 4 4, 1 9 93 .4. Anusav ice KJ ,Effi cacy o f nonsurg ical management o f t heinitial caries lesion. J Denta l Education 61:895-905, 1997.5. Zero DT,Fontana M, Lennon AM, Clin ical app lications andoutcomes of using indicators of r isk incaries management.JDent Educ 65(10):1126-32, 2001.6. Featherstone JD,The car ies balance: contr ibut ing factors andearly detection. J Cal Dent AssoC31(2):129-33 , February 2003.7. Featherstone JDB. The caries balance: t he bas is fo r cariesmanagement by risk assessment . Oral Health Prev Dent2(Suppl1):259-64,2004.8. Featherstone JD, Gansky SA, et al. A randomized clinicaltri al o f caries management by r isk assessment. Car ies Res39(4):295,2005.

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9. Curnow MMT, Pine CM, e t a l. A randomized control led tr ia lof the eff icacy of supervised toothbrushing in high-caries-r iskchi ldren. Car ies Res 36(4) :294-300, July-August 2002.

TO REQ.UEST A PRINTED COPY OF THIS ARTICLE, PLEASECONTACT John D.B.Featherstone, MSc, PhD, University ofCa li fo rn ia , San Franci sco, Department o f Preventive andRestorative Dental Sciences, 707 Parnassus Ave., Box 0758,San Francisco, Calif ., 94143.


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D ea r ( Pa tie nt Z ),O ur assessm ent indicates that you are at ex trem e risk of new dental decay in the near future b ecause you have (fill in the b lank) and you havesev ere "d ry m ou th " d ue to (fill i n t he b lan k). W e w an t y ou to m ove to a safer situatio n to av oid n ew d ecay if at all p ossib le. P lease d o th e fo llo win gr igh t away : C om plete a caries b acterial test w ith us today (as a b ase line b efore antibacterial therapy) . W e w ill know the results of this test in three days. C om plete a saliva flow m easurem ent to confirm your ex trem e dry m outh. T his is a very sim ple test that w e w ill c om plete today as part of thebac te r ia l a s se s sment. R eview your dietary and oral hygiene hab its w ith us and receive instructions ab out how to im prove them b oth. T he m ost im portant thing is tored uce th e n um ber o f b etw een -m eal sw eet sn ack s th at co ntain carb oh yd rates, esp ecially su gar. S ub stitutio n b y sn ack s rich in p ro tein , su ch as

ch eese, w ill a lso h elp as w ell as th e x ylito l g um o r can dies reco mm en ded b elo w. B ru sh tw ice d aily w ith a n ew stro ng to oth paste, eith er C on tro l R X o r P rev id en t P lu s to oth paste (5 ,0 00 p arts p er m illio n flu orid e). W e w ill p ro -v id e y ou w ith so me tod ay . T his is to b e u sed tw ice d aily in p lace o f y ou r reg ular to oth paste. R in se for o ne m in ute, o nce a d ay w ith a sp ecial an tib acterial m ou th rin se th at w e w ill p ro vid e y ou w ith to day . It i s called P eridex o r P erio gard

a nd h as an a ctiv e in gr ed ie nt c alled ch lo rh ex id in e g lu co nate a t 0.12 p ercen t. Y ou w ill u se th is o nce d aily ju st b efo re g oin g to b ed at n ig ht (10 mlfo r o ne m in ute), b ut o nly fo r o ne w eek each m on th. Y ou m ust u se th is at least o ne h ou r after b ru sh in g w ith th e 5 ,0 00 p pm flu orid e to othp aste. G et a fluoride varnish treatm ent for all of your teeth every three m onths at your caries recall ex am s. R eceiv e th e n ecessary resto rativ e w ork su ch as fillin gs an d cro wn s, as n eed ed , in a m in im ally in vasiv e fash io n. Suck or chew x ylitol candies or gum four tim es daily . Y ou can ob tain supplies from us today or w e can help you b uy these elsew here. U se a special paste that contains calcium and phosphate (e.g., M l p aste) . A pply it several tim es daily to your teeth. W e w ill t each you how to doth is prope r ly . O btain a th oro ug h p rofessio nal clean in g d urin g y ou r cu rren t v isit. G et a sealant treatm ent on all of the b iting surfaces of your b ack teeth to keep them from b eing reinfected w ith the b acteria that cause dentaldecay. U se a b ak ing so da rin se ( or sim ilar n eu traliz in g p ro du ct) fo ur to six tim es d aily d urin g th e d ay . Y ou can m ak e th is y ou rself b y sh ak in g u p tw o tea-sp oo ns o f b ak in g so da in an eig ht-o un ce b ottle o f w ater. Please return w hen called for a re-evaluation in ab out one m onth. Please return w hen req uested for a caries recall ex am in three m onths. G et n ew b itew in g rad io grap hs (X -ray s) ab ou t ev ery six m on ths un til n o cav itated lesio ns are ev id en t. C om e in for another caries b acterial test at the three-m onth visit or sooner to com pare results w ith your first visit to check w hether thech lorhex i d ine i s work ing sa ti sfa ct o ri ly . R eceiv e a rev iew o f y our u se o f ch lo rhex id in e an d C on tro l R X/P revid en t an d o ral h ygien e at that v isit. C om e in fo r a th orou gh p ro fessio nal clean in g as n eed ed fo r y ou r p erio do ntal h ealth . G et an oth er flu orid e v arn ish treatm en t o f all teeth ag ain at th ree-m on th caries recall v isit an d ano ther set o f b itew in g X -rays at six m on th s.W e w ill p ro vid e y ou w ith a tim etab le to h elp y ou to rem em ber all o f th ese pro ced ures.A lth ou gh th is so un ds lik e a lo t o f th in gs to d o an d to rem em ber, this in ten siv e th erap y is n ecessary to sto p th e rap id d estru ctio n o f y ou r teeth .I t can really w ork , an d if y ou are w illin g to p ut in th e tim e an d effo rt, y ou can clear u p y ou r m ou th , g um s, an d teeth an d av oid co stly resto ratived ental w ork in th e fu tu re. P lease h elp u s to h elp y ou .

Practitioner signature Date _

Patient signature Date _

FIG URE 6. E x tr em e c ar ie s r is k ( hi gh r is k p lu s s ev er e s al iv ar y g la nd h yp of un ct io n) .

OCTOBER 2007 713

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